PALPITATIONS:

What they are and what to do about them.

 “Fill what's empty, empty what's full, and scratch where it itches."

- The Duchess of Windsor, when asked what is the secret of a long and happy life

Palpitations are heartbeat sensations that may feel like your heart is pounding, racing, jumping or skipping a beat.  They can occur with other symptoms (shortness of breath, chest pain, dizziness) and can last for a few seconds to a few hours. 

Palpitations may be caused by abnormal heart rhythms called arrhythmias.  Some patients can simply have increased awareness of their heart beat during times of stress and anxiety, and in these patients no heart disease or abnormal heart rhythms can be found.  However, palpitations can also be a presenting symptom for serious heart conditions.

In order to understand what arrhythmias are and why they happen, we need to understand how the electrical system of the heart normally works.  Normal resting adult heart beats regularly at an average rate of 60 to 100 times per minute. How fast the heart beats is governed by the speed of electrical signals originating from the pacemaker of the heart, the SA node. The electrical signals from the SA node travel across the two upper heart chambers (atria) resulting in contraction of these chambers and delivering blood into the lower heart chambers, the ventricles. These electrical signals then pass through the AV node to reach the ventricles and also cause these chambers to contract, pumping blood to the rest of the body, generating the pulse. During rest, the speed of electrical signals originating from the SA node is slow, thus the heart beats slowly. During exercise or excitement, the speed of signals from the SA node increases, and heartbeat quickens.  Arrhythmias occur when there is malfunction of any part of this perfectly designed electrical system.  In some patients, arrhythmias are caused by diseases of the heart muscle, valves or coronary arteries. In others, arrhythmias can reflect disease of the electrical system of the heart only, while the rest of the heart is healthy. Other causes of arrhythmias include medications, alcohol excess, excessive levels of thyroid hormone, low blood oxygen levels etc…

Since some arrhythmias can be life threatening if left untreated, the first step in the evaluation of patients with palpitations is to determine whether their symptoms are due to arrhythmias. Because the treatment of varying types of arrhythmias can differ, it is also important to determine the type of arrhythmia involved.  Tests that are used to detect abnormal heart rhythms include resting EKG, 24-hour rhythm monitoring (Holter), and event monitoring (monitor that is activated by patients when they have symptoms). As we mentioned previously, arrhythmias can be related to underlying disease of the heart valves, heart muscle, and coronary arteries, therefore exercise stress test and echocardiography (ultrasound of the heart) are often performed to exclude these heart abnormalities. 

Fortunately, most arrhythmias are treatable.  Certain types require no specific treatment and simple interventions like stopping cigarettes, and reducing caffeine and alcohol consumption will be adequate.  Often medications called anti-arrhythmics are used.  Sometimes, electrical cardioversion (delivering direct electrical current to the chest wall after patients are put to asleep) is necessary to restore normal rhythm.  Blood thinners might need to be used to prevent strokes.  Pacemakers might be indicated for patients with slow heart rhythms.  Implantable defibrillators are considered in patients with life threatening arrhythmias.  In the last decade, radio-frequency ablation (the destruction of abnormal electrical pathways by using local heating via special catheters) has emerged as an extremely effective way of eliminating certain types of arrhythmias, often resulting in a cure.   In patients with arrhythmias associated with significant heart muscle or valve disease, correction of the underlying heart disease is also very important.

All of this leads to one simple conclusion; patients experiencing palpitations should seek medical attention as soon as possible.  This is especially important for those who are above 40 years old, who are experiencing other symptoms like chest pain, lightheadedness or syncope (passing out) or who already have other heart conditions like coronary artery disease, hypertension or cardiomyopathy (weakness of the heart muscle). 

We hope that this article answered some of your questions about a very common, anxiety producing symptom, “palpitations”.  Stay healthy.

Yamac Gungor, MD

(The author has no financial incentive to promote any particular brand or type of therapy.)